Intervention

Wards were pair matched by Jarman score. 20 wards (73 399 households) were allocated to the intervention, which comprised
distribution (door to door and through key local sites) of smoke alarms, with batteries, fittings, and fire safety brochures
(in English and other local languages) targeted to households at high risk. Free installation was offered. One year later,
postcards were sent to remind recipients to change the smoke alarm batteries. The aim was to provide smoke alarms to 25% of
intervention households. 20 wards (74 045 households) were allocated to the control group and received no intervention.

Main outcome measures

Main outcome was fire related injuries resulting in attendance at an emergency department, hospital admission, or death. Any
injury that resulted from fire in an occupied dwelling of a study ward was included. Other outcomes included fires attended
by the fire brigade.

Main results

20 050 alarms were distributed to 19 950 households. The intervention and control groups did not differ for total fire related
injuries, or hospital admissions and deaths (table). Similar results were found for the 78% of injuries judged to be potentially
preventable by smoke alarms (table). The fire brigade attended 1603 residential fires. The groups did not differ for the incidence
of attended fires.

Conclusion

Commentary

Assistant Professor, School of Nursing, McMaster University Hamilton, Ontario, Canada

Rarely is a primary prevention trial of personal safety so well designed and conducted as the study by DiGuiseppi et al. Although the results were negative, the rigour of the cluster randomised design and the attention to other methodological
aspects leaves little doubt as to the veracity of the principal outcome. DiGuiseppi et al replicated many of the intervention features of a study by Mallonee et al, which was conducted in an economically deprived neighbourhood in Oklahoma City, USA.1 Both studies distributed similar alarms to a similar proportion of the population, and both involved community members and
government and voluntary agencies in the distribution process. However, DiGuiseppi et al did not find the favourable results of Mallonee et al. In fact, DiGuiseppi et al found that the intervention and control households had similar proportions of alarms installed and operational. In other
words, the participants did not use the safety device as instructed.

One explanation for the differences in the findings of DiGuiseppi et al and Mallonee et al might relate to differences in the study populations. DiGuiseppi et al suggest that their participants may have had lower literacy levels and greater difficulty understanding the installation
and maintenance instructions. Furthermore, factors such as mistrust of people in positions of authority and the fact that
most recipients were tenants rather than homeowners may have reduced installation rates in the study by DiGuiseppi et al.

The results are important for nurses and others working in the community. The role of community assessment in tailoring interventions
to local populations cannot be overemphasised. Furthermore, a community assessment process using multiple culturally appropriate
methods, particularly in a multiethnic population such as in the UK study, can support the trust building phase that DiGuiseppi
et al identified as a key barrier to the implementation of their intervention.

A recurrent theme in injury prevention is the preference for passive prevention strategies rather than the active ones used
by DiGuiseppi et al.2 This study suggests a continued role for public health practitioners in advocating for policy changes such as affordable,
safe housing, and passive interventions, like sprinkler systems and appropriate building code regulations.2

Footnotes

Sources of funding: Medical Research Council; Home Office (Fire Research and Development Group and National Community Fire
Safety Centre); Department of Health; Camden and Islington Councils; British Medical Association; Camden and Islington Health
Authority.